The Suicide The Suicide Spectrum in Spectrum in

Delaware CountyDelaware CountyFredric N. Hellman, M.D., Fredric N. Hellman, M.D.,

M.B.A.M.B.A.

Chief Medical Examiner, Chief Medical Examiner, Delaware County, PADelaware County, PA

Role of the Medical Role of the Medical ExaminerExaminer

Identification: presumptive vs Identification: presumptive vs confirmatoryconfirmatory

Estimation of Time of DeathEstimation of Time of Death Documentation of Injuries/PathologyDocumentation of Injuries/Pathology Collection of Trace EvidenceCollection of Trace Evidence Determination of Cause & Manner of Determination of Cause & Manner of

DeathDeath

Manner of DeathManner of Death

A classification of the way in which the A classification of the way in which the cause of death came about, with special cause of death came about, with special reference to social relationships and reference to social relationships and personal causationpersonal causation

Categories:Categories: NaturalNatural AccidentAccident SuicideSuicide HomicideHomicide UndeterminedUndetermined

The Medical Examiner’s The Medical Examiner’s Role in Potential Suicide Role in Potential Suicide

InvestigationInvestigation The medical examiner is responsible The medical examiner is responsible

for the investigation of any for the investigation of any unexplained, unexpected, mysterious unexplained, unexpected, mysterious or violent deathor violent death

In the case of potential suicide, the ME In the case of potential suicide, the ME must attempt to ascertain, to a must attempt to ascertain, to a reasonable degree of medical reasonable degree of medical certainty, both intent towards self-certainty, both intent towards self-destruction and a subsequent lethal actdestruction and a subsequent lethal act

The Medical Examiner & The Medical Examiner & You You

Suicide has been a serious health problem for Suicide has been a serious health problem for many years, but has only recently acquired many years, but has only recently acquired the attention that it meritsthe attention that it merits

Every year, approximately 30,000 individuals Every year, approximately 30,000 individuals die by suicide in the U.S., and one million die die by suicide in the U.S., and one million die worldwideworldwide

More than 650,000 people annually receive More than 650,000 people annually receive emergency treatment after a suicide attempt emergency treatment after a suicide attempt in this countryin this country

Suicide is the third-leading COD amongst Suicide is the third-leading COD amongst American youth, being #11 for Americans American youth, being #11 for Americans across all agesacross all ages

National Suicide RatesNational Suicide Rates

While having remained fairly stable While having remained fairly stable through time among this country’s through time among this country’s general population (12.1/100,000 general population (12.1/100,000 (1976); 10.8/100,000 (1996)), (1976); 10.8/100,000 (1996)), substantial shifts in suicide rates substantial shifts in suicide rates have been observed amongst various have been observed amongst various age, gender, & ethnic groupsage, gender, & ethnic groups

National Suicide RatesNational Suicide Rates

While females are more likely than While females are more likely than males to attempt suicide, males are males to attempt suicide, males are 4X as likely to be successful4X as likely to be successful

White males/females accounted for White males/females accounted for over 90% of suicides in 1997, with over 90% of suicides in 1997, with white males alone responsible for white males alone responsible for 72%72%

Firearm-related deaths accounted Firearm-related deaths accounted for 58% of all suicides in 1997for 58% of all suicides in 1997

Suicide-Regional Suicide-Regional VariationVariation

Suicide rates have varied by Suicide rates have varied by geographic region, being geographic region, being consistently higher in the Western consistently higher in the Western statesstates Reasons are unclear, but may reflect Reasons are unclear, but may reflect

regional differences in certain regional differences in certain demographic variables (Suicide rates demographic variables (Suicide rates are known to be higher for the elderly, are known to be higher for the elderly, for white males, & for certain for white males, & for certain racial/ethnic groups)racial/ethnic groups)

Suicide-Regional Suicide-Regional VariationVariation

From 1990-1994, 154,444 persons From 1990-1994, 154,444 persons were reported to complete suicide in were reported to complete suicide in the U.S.the U.S. Northeast: 23,734 (15%)-8.6/100,000Northeast: 23,734 (15%)-8.6/100,000 Midwest: 34,492 (22%)-10.9/100,000Midwest: 34,492 (22%)-10.9/100,000 West: 38,709 (25%)-14.1/100,000West: 38,709 (25%)-14.1/100,000 South: 57,509 (37%)-13.1/100,000South: 57,509 (37%)-13.1/100,000 Total U.S. adjusted suicide rate during Total U.S. adjusted suicide rate during

this period-11.8/100,000this period-11.8/100,000

Suicide-Regional Suicide-Regional VariationVariation

Reasons other than for possible Reasons other than for possible regional differences in certain regional differences in certain demographics:demographics: Suicide rates are higher in communities Suicide rates are higher in communities

with deficient social integration & with deficient social integration & unstable social environmentsunstable social environments

Limited economic opportunity with Limited economic opportunity with increased unemployment as well as increased unemployment as well as residential instability may also residential instability may also contribute to an elevated suicide ratecontribute to an elevated suicide rate

More Suicide StatisticsMore Suicide Statistics

Suicide rates are inversely related to Suicide rates are inversely related to level of educationlevel of education

The incidence of suicide is also The incidence of suicide is also significantly lower among married significantly lower among married individuals than among those who individuals than among those who are single, separated, divorced or are single, separated, divorced or widowedwidowed

Suicide Among YouthSuicide Among Youth

The Problem: Rates of reported The Problem: Rates of reported suicides among adolescents & young suicides among adolescents & young adults have nearly tripled between adults have nearly tripled between 1952 & 19961952 & 1996 1950: 4.5/100,0001950: 4.5/100,000 1990: 13.5/100,0001990: 13.5/100,000

Suicide Among YouthSuicide Among Youth

Suicide is now the 4Suicide is now the 4thth leading cause leading cause of death amongst children aged 10-of death amongst children aged 10-14 years14 years

Suicide is the 3Suicide is the 3rdrd leading cause of leading cause of death amongst adolescents aged 13-death amongst adolescents aged 13-24 years, exceeded only by 24 years, exceeded only by unintentional injury & homicideunintentional injury & homicide

Suicide Among YouthSuicide Among Youth

Risk Factors include: Risk Factors include: Family history of suicideFamily history of suicide Impulsive/aggressive behaviorImpulsive/aggressive behavior Social isolationSocial isolation Prior suicide attempt(s)Prior suicide attempt(s) Easier access to alcohol, illicit drugs & Easier access to alcohol, illicit drugs &

lethal suicide methodslethal suicide methods

Suicide Suicide Ideation/Attempts Ideation/Attempts

Among YouthAmong Youth While suicide represents the 3While suicide represents the 3rdrd

leading cause of death among U.S leading cause of death among U.S teens, many more seriously consider teens, many more seriously consider suicide w/o attempting or attempt suicide w/o attempting or attempt w/o completing the actw/o completing the act

Suicide Suicide Ideation/Attempts Ideation/Attempts

Among YouthAmong Youth 1999: 20% of all H.S. students 1999: 20% of all H.S. students

acknowledged having seriously acknowledged having seriously considered or attempted suicide considered or attempted suicide during the prior yearduring the prior year 8% actually attempted suicide8% actually attempted suicide Less than 3% reported an injurious Less than 3% reported an injurious

episode necessitating medical attentionepisode necessitating medical attention

The Suicide Profile-The Suicide Profile-Delaware CountyDelaware County

Suicide rates & associated demographic Suicide rates & associated demographic data were tracked from 1990-2006data were tracked from 1990-2006

Deaths due to suicide during this Deaths due to suicide during this period: 933, with 904 initiated within period: 933, with 904 initiated within Delaware Co.Delaware Co.

Per annum range: 45-69, with a Per annum range: 45-69, with a median=55 & a mean=56 deathsmedian=55 & a mean=56 deaths

Based upon a county Based upon a county population=547,651, the 1990 suicide population=547,651, the 1990 suicide rate per 100,000 individuals=10.4rate per 100,000 individuals=10.4

The Suicide Profile-The Suicide Profile- Delaware County Delaware County

Utilizing the Delaware Valley Utilizing the Delaware Valley Regional Planning Commission est. Regional Planning Commission est. population in 2000(549,070):population in 2000(549,070):-DELCO suicide rate(2006)=10.1-DELCO suicide rate(2006)=10.1

The Suicide Profile-The Suicide Profile-Delaware CountyDelaware County

By gender & race, suicide was By gender & race, suicide was successfully completed by 210 successfully completed by 210 females (22.5%) & 723 males females (22.5%) & 723 males (77.5%). All but 116 such acts were (77.5%). All but 116 such acts were completed by Caucasians (88%), completed by Caucasians (88%), with the vast majority of suicides with the vast majority of suicides being completed by Caucasian males being completed by Caucasian males (71%).(71%).

The Suicide Profile-The Suicide Profile-Delaware CountyDelaware County

Suicide rate by race(1990/1998):Suicide rate by race(1990/1998): White-8.4/7.2White-8.4/7.2 Black-4.9/7.2Black-4.9/7.2 Asian-0/0Asian-0/0 Hispanic-16.7/0Hispanic-16.7/0

Suicide at the Extremes-Suicide at the Extremes-Delaware CountyDelaware County

Between 1990-2006, 61 individuals Between 1990-2006, 61 individuals (6.5%) between the ages of 16-20 (6.5%) between the ages of 16-20 years completed suicide, with 153 years completed suicide, with 153 additional suicides (16.4%) among additional suicides (16.4%) among those aged 21-30 yearsthose aged 21-30 years

At the opposing end of the age At the opposing end of the age spectrum, 221 persons 61 years of spectrum, 221 persons 61 years of age or older (18.8%) completed age or older (18.8%) completed suicide during this period of timesuicide during this period of time

DelawareDelaware County Suicide County Suicide Rate Rate

(1990-2006)(1990-2006)

0

10

20

30

40

50

60

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Year

# S

uic

ides

Total

> 60 yrs

Delaware County Delaware County DemographicsDemographics

A total of 65 boroughs, townships and A total of 65 boroughs, townships and communities comprised the study communities comprised the study distribution of completed suicides within distribution of completed suicides within the county during the period 1990-2006.the county during the period 1990-2006. Two communities were without completed Two communities were without completed

suicides during this timeframe (Corcordville, suicides during this timeframe (Corcordville, Lester)Lester)

Eight communities outside of the county Eight communities outside of the county contributed 29 suicides during this period contributed 29 suicides during this period (inciting act versus location of pronouncement (inciting act versus location of pronouncement of death)of death)

Adjusted Delaware County suicide rate (1990-Adjusted Delaware County suicide rate (1990-2006): 9.82006): 9.8

Delaware County Delaware County DemographicsDemographics

Community population range (2000 Community population range (2000 census data):census data): Largest population: Upper Darby (81,529)Largest population: Upper Darby (81,529) Smallest population: Ruttledge (852)Smallest population: Ruttledge (852)

Per capita income (PCI) range:Per capita income (PCI) range: Highest PCI: Rose Valley ($54.2K)Highest PCI: Rose Valley ($54.2K)

Suicide rate/100,000: 11.3Suicide rate/100,000: 11.3 Lowest PCI: Chester City ($13.1K)Lowest PCI: Chester City ($13.1K)

Suicide rate/100,000: 12.1Suicide rate/100,000: 12.1 Mean PCI: $25.0KMean PCI: $25.0K

Delaware County Delaware County Household DemographicsHousehold Demographics

Married couples (104,911) versus Married couples (104,911) versus single-parent households (26,542): single-parent households (26,542): 4.0:14.0:1 Highest ratio: Thornbury (16.1:1), with Highest ratio: Thornbury (16.1:1), with

PCI = $22.0KPCI = $22.0K Suicide rate/100,000: 10.1Suicide rate/100,000: 10.1

Lowest ratio: Chester City (0.8:1), with Lowest ratio: Chester City (0.8:1), with PCI = $13.1KPCI = $13.1K Suicide rate/100,000: 12.1Suicide rate/100,000: 12.1

Delaware County Delaware County Household DemographicsHousehold Demographics

Households of those 65+ years & Households of those 65+ years & alone: 5,792 M and 18,057 Falone: 5,792 M and 18,057 F Highest % per total community Highest % per total community

population: Edgemont (7.3%)population: Edgemont (7.3%) Suicide rate/100,000: 20.1Suicide rate/100,000: 20.1

Lowest % per total community Lowest % per total community population: Bethel (1.1%)population: Bethel (1.1%) Suicide rate/100,000: 7.6Suicide rate/100,000: 7.6

Average %: 4.5%Average %: 4.5% Suicide rate/100,000: 9.8 Suicide rate/100,000: 9.8

Delaware County Delaware County Demographics Educational Demographics Educational

LevelLevel Delaware County residents with Delaware County residents with

educational attainment of bachelor’s educational attainment of bachelor’s degree or above: 109,670 out of 355,174 degree or above: 109,670 out of 355,174 residents 25+ years of age (30.0%)residents 25+ years of age (30.0%) Community with highest % of residents with Community with highest % of residents with

educational attainment of bachelor’s degree or educational attainment of bachelor’s degree or above: Swarthmore (2,618/3,395 (77.1%)) above: Swarthmore (2,618/3,395 (77.1%))

Suicide rate-13.3Suicide rate-13.3

Community with lowest % of residents with Community with lowest % of residents with educational attainment of bachelor’s degree or educational attainment of bachelor’s degree or above: Chester City (1,804/21,174 (0.85%)) above: Chester City (1,804/21,174 (0.85%))

Suicide Rate-12.1 Suicide Rate-12.1

Community Suicide Rate Community Suicide Rate DemographicsDemographics

Communities with suicide rates of Communities with suicide rates of 14.1/100,000 or greater: 14/6514.1/100,000 or greater: 14/65 Range: 14.1-48.1/100,000Range: 14.1-48.1/100,000 Mean: 21.9/100,000Mean: 21.9/100,000

Communities with suicide rates of Communities with suicide rates of 7.0/100,00 or less: 11/657.0/100,00 or less: 11/65 Range: 4.2-7.0/100,000Range: 4.2-7.0/100,000 Mean: 5.8/100,000Mean: 5.8/100,000

Community Suicide Rate Community Suicide Rate DemographicsDemographics

Communities with suicide rates of Communities with suicide rates of 14.1/100,000 or greater: 14.1/100,000 or greater: PCI: $21.9KPCI: $21.9K Married : Single parent households: Married : Single parent households:

3.6:13.6:1 Households of 65+ years & alone: Households of 65+ years & alone:

4.85%4.85% Educational attainment of bachelor’s Educational attainment of bachelor’s

degree or above: 18.4%degree or above: 18.4%

Community Suicide Rate Community Suicide Rate DemographicsDemographics

Communities with suicide rates of Communities with suicide rates of 7.0/100,000 or less: 7.0/100,000 or less: PCI: $29.4KPCI: $29.4K Married : Single Parent household: 7.1:1Married : Single Parent household: 7.1:1 Households of 65+ years & alone: 4.35%Households of 65+ years & alone: 4.35% Educational attainment of bachelor’s Educational attainment of bachelor’s

degree & above: 40.6%degree & above: 40.6%

Suicide Risk FactorsSuicide Risk Factors

Suicide rates are higher in Suicide rates are higher in communities with deficient social communities with deficient social integration & unstable social integration & unstable social environmentsenvironments

Limited economic opportunity with Limited economic opportunity with increased unemployment as well as increased unemployment as well as residential instability may also residential instability may also contribute to an elevated suicide contribute to an elevated suicide raterate

Suicide AssociationsSuicide Associations

Suicide rates are inversely related to Suicide rates are inversely related to level of educationlevel of education

The incidence of suicide is also The incidence of suicide is also significantly lower among married significantly lower among married individuals than among those who individuals than among those who are single, separated, divorced or are single, separated, divorced or widowedwidowed

Suicide AssociationsSuicide Associations

Suicide rates are known to be higher Suicide rates are known to be higher for the elderly, for white males, & for the elderly, for white males, & for certain racial/ethnic groupsfor certain racial/ethnic groups

Suicide Among YouthSuicide Among Youth

Risk Factors include: Risk Factors include: Family history of suicideFamily history of suicide Impulsive/aggressive behaviorImpulsive/aggressive behavior Social isolationSocial isolation Prior suicide attempt(s)Prior suicide attempt(s) Easier access to alcohol, illicit drugs & Easier access to alcohol, illicit drugs &

lethal suicide methodslethal suicide methods

Suicide Among the Suicide Among the ElderlyElderly

Risk factors include:Risk factors include: WidowhoodWidowhood Serious medical illness, with associated Serious medical illness, with associated

anxietiesanxieties Social isolationSocial isolation DepressionDepression Alcoholism & prescription drug abuseAlcoholism & prescription drug abuse Financial constraintsFinancial constraints

The Surgeon General’s The Surgeon General’s Call To ActionCall To Action

The public health approach:The public health approach: Define the problemDefine the problem Identify the causes & protective factorsIdentify the causes & protective factors Develop & test interventionsDevelop & test interventions Implement interventionsImplement interventions